Interdisciplinary Documentation ofPatient Education: How CollaborationCan Effect Change

Susan T. McCoy, RN CRRNKelly A. Cope, BSW CCMSusan J. Joy, BSN RN CRRNRichard T. Baker, RN CRRNChristine J. Brugler, MSN RN

Changing healthcare trendsare af­fecting all healthcareproviders today,including those at Hillside Rehabili­tation Hospital. Computerizing the in­terdisciplinary documentation ofpa­tient information was one changeHillside's leaders implemented to re­main competitive and cost-effective.The benefits ofmoving from a hand­written documentation system to acomputerized system were many.However; unforeseen difficulties withretrieving data became evident be­cause the system was not developedto accommodate information aboutpatient education. Through interdis­ciplinary collaboration, staff identi­fied areas for improvement and madechanges to the documentation pro­cess. They developed a "travelingcard" for documenting patient edu­cation and then met a new set ofchal­lenges. The new documentation sys­tem met departmental and JointCommission on Accreditation ofHealthcare Organizations require­ments for comprehensive patient ed­ucation and documentation.

Address correspondence to Susan T.McCoy, RN CRRN, Case Manager;Hillside Rehabilitation Hospital,8747 Squires Lane, NE, Warren, OH44484.

Hillside Rehabilitation Hospital is a freestanding 93-bed facility in northeastern Ohiothat provides acute physical rehabilitation services. For more than 25 years, Hillside'shealthcare professionals have provided a multidisciplinary approach to patient care,which involves "activities of individuals from various disciplines who are required toknow only the skills of their own discipline" (McCourt, 1993, p. 182).

In the early 1990s, hospital leaders reviewed the facility's approach to patient careand envisioned future trends and possibilities. At that time, two major forces influencedtheir discussions. The first was the changing healthcare trend emphasizing an interdis­ciplinary approach to care, such as "activities performed by team members from differ­ent disciplines to reach a common goal" (McCourt, 1993, p. 180). The second was theneed to decrease costs associated with patient care. Hospital leaders began strategizingto find the best way to move to a more cost-effective interdisciplinary approach. Onesolution was to implement interdisciplinary computerized documentation. The hospi­tal's departments were computerized in February 1994; however, new concerns surfacedwith the advent of this change.

Meeting the challenges of computerized documentationInternal reviewers of utilization and quality, as well as the hospital's medical records

committee, identified that retrieving any documentation on patient education (either con­current or retrospective) was difficult with the computerized system. With the previousmultidisciplinary handwritten approach, staff could easily find documentation in eachpatient's chart, where it was organized by department in specifically designated sections.Nurses had used a separate teaching record for documentation, whereas other profes­sionals included documentation of their teaching in their progress notes. The softwareprogram, however, provided no way to easily retrieve information about education thathad been provided for the patients. Because all documentation appeared on the com­puter screen in the order it was entered, any documentation concerning education was"lost" in the department's progress notes for each patient. Also, because therapistsneeded time to complete discharge summaries and documentation, a hard copy of thepatient's chart was not available until 7 days after discharge, and even then, informationconcerning patient education was buried in the numerous pages of documentation.

At about the same time that concerns arose about this documentation, hospital ad­ministrators sent four members of the hospital's committee on improving organization­al performance to a seminar on how to effectively prepare for a survey. The seminar wasdesigned to familiarize staff with the new Joint Commission on Accreditation of Health­care Organizations (JCAHO) standards, which are updated each year. After attendingthe seminar, the committee members confirmed the validity of the concerns ofboth staffand administrators regarding meeting the new and revised JCAHO standards, especial­ly in regard to documentation and patient education.

The hospital implemented two strategies to ensure that documentation of patient careand education, along with other areas of concern (e.g., safety), would meet standards.

Rehabilitation Nursing> Volume 22, Number 5· Sept/Oct 1997 235

Interdisciplinary Documentation

First, administrators hired a team to do a mock JCAHO surveyof the hospital and identify in detail all actual and potential prob­lem areas. Second, the committee on improving organization­al performance selected one of its members-a rehabilitationnurse case manager-to coordinate and implement the revisedJCAHO standards on patient education.

The mock survey team spent 2 days at the hospital inter­viewing staff in every department about the JCAHO standards.They collected, reviewed, and analyzed data to identify strengthsand weaknesses. Overall, the hospital did well during the sur­vey; however, as had been suspected beforehand, the area ofpatient education documentation could potentially receive fourJCAHO Type I recommendations, which would require follow­up before full accreditation could be granted.

The nurse case manager supervised the coordination of thechanges needed to correct areas of concern. First, the form fornotes recorded during patient team conferences was revised toinclude patient and family learning needs as well as a processfor prioritizing identified patient problem areas (see Figure 1).Next, because each department's education manual reflectedits own area of expertise, patient education materials had notbeen shared with other departments in the past. Therefore, everydepartment was asked to submit all of its educational materialsto one central location where new manuals, which included allmaterials, were formatted and distributed. Each department was

then able to view all of the materials disseminated by other dis­ciplines, which reinforced the interdisciplinary teaching process.

The most complex changes related to making up for the lackof an interdisciplinary teaching record and an interdisciplinaryeducation council. Because the new software program was stillbeing developed, retrieving computerized interdisciplinary pa­tient education records was not immediately possible.

Because the hospital's education committee had historical­ly been composed of nurses, the nurse case manager met withthe nurse managers to discuss how to best make changes with­in the committee, to describe the deficiency related to the teach­ing record and seek possible solutions, and to begin the processof developing a new interdisciplinary teaching record. Therecord would document patient education and would be acces­sible to all departments. In addition, as patients traveled through­out the hospital for their respective therapies, the record wouldneed to accompany the patient. A decision was made at thismeeting to reorganize the nurses' education committee to be aninterdisciplinary education council (1EC).

Developing an interdisciplinary teaching recordThe nurse case manager served as the facilitator at the IEC

meetings. Twenty representatives from direct and indirect patientcare departments attended the initial meeting. The nurse casemanager opened the meeting by outlining the goals for the com-

Figure 1. Hillside Rehabilitation Hospital's Team Note

Progress Prioritization of problems Plans

Basic transfers _

Advanced transfers

Ambulation assistanceDistance _

Device

Stairs

Goal

Goal

Goal

Goal

Goal

Goal

Continued inpatient hospital care necessary per above-stated plans and length of stay of more days/weeks

The patient will be reviewed by team in 0 I week 0 2 weeks Discharge date Follow-up date _

ServicesPhysicaltherapyx_ Occupational therapyx _ Speechtherapyx _ Psychology x _ Homehealthaide x _ Otherx _

Case manager

__________________ MD

Discharge plan 0 Own home 0 Alone 0 Family assistanceo Nursing home 0 With hired assistance

PatientIFamily Learning Needs

o Self-care

o Sphincter control

o Mobility: Transfers, locomotion

o Communication

o Psychsocial adjustment

o Cognitive function

o Special treatment needs

o Medications

o Home of family mermbero Other _

__________________ Date

____ Discharge team Family team conference

Members Present at Team Conference____ Nurse Speech____ PT Psych____ OT Other____ First team Interim team

Reprinted with permission from Hillside Rehabilitation Hospital

236 Rehabilitation Nursing> Volume 22, Number 5' Sept/Oct 1997

mittee and emphasized the need to develop and implement aworkable interdisciplinary teaching record within the next 3weeks. Rapid implementation was critical for demonstrating 6months of compliance, which is required for the officialJCAHO survey. (Hillside's official JCAHO survey was sched­uled to occur approximately 6 months later.) The case manag­er explained the criteria for the form: It had to be accessible toall disciplines, demonstrate strengths and barriers to patient andfamily learning, and become part of the patient's permanentrecord.

The council reviewed several examples of interdisciplinaryteaching records (ITRs) used at other facilities and discussedmany aspects of the examples, along with the needs of specif­ic departments. Within 2 hours, the interdisciplinary discus­sions led to the development of a working ITR (see Figure 2),which met the initial criteria of patient education documenta­tion for all of the hospital's departments and the JCAHO re­quirements. The council also decided to print the record ondurable white card stock because many different staff memberswould be handling the documentation tool.

Teaching staff about the new ITRThe importance of the ITR and the upcoming JCAHO sur­

vey made it imperative that all staff be fully aware of this newpatient and family education tool and that they comply with it.Therefore, once the ITR form was formatted, a process for ed­ucating staff was necessary. A case manager (who was also alicensed social worker) worked with all of the hospital's de­partments to ensure that this staff education was implemented.

In-service programs to explain the ITRs were scheduled foreach of the four patient care services (nursing, dietary, psy­chology, and case management) and five clinical areas (physi­cal, occupational, speech, recreational, and respiratory thera­pies) whose professionals would be documenting their patienteducation efforts on the ITR. These programs included directinstruction on the purpose and uses of the ITR as well as on thedocumentation procedure. To emphasize the importance oftheITR, the in-service educator reviewedthe possible JCAHO TypeI recommendations regarding education discovered earlier bythe mock survey team. She then presented strategies for com­plying with these potential recommendations and explanations

Figure 2. Hillside Rehabilitation Hospital's Interdisciplinary Teaching Record (Abbreviated)

Learner codes Barrier codes Method codes Evaluation codesPT= Patient L= Language V= Video VU =Verbalizes understandingSP= Spouse CR = Cultural/Religious D = Demonstration D = Demonstrates without assistance

P= Parent E = Emotional I = One-to-one DP = Demonstrates with assistanceOR = Other relative M = Motivation G= Group NR = Needs reinforcementSO = Significant other PH = Physical H= Handout NA =Learning not accomplishedCG = Caregiver C = Cognitive L= Lecture **= No evidenceoflearning (explain)

Ne None Ae AudioH=Hearing PC = PhoneconferenceV=VisionP=Pain0= Other

*Anasterisk indicates that more details canbe found in thepatient's computerized entry.

Reprinted withpermission from Hillside Rehabilitation Hospital

Rehabilitation Nursing' Volume 22, Number 5' Sept/Oct 1997 237

Interdisciplinary Documentation

ofhow the ITR would enhance the documentation process. Dueto the need for immediate implementation, these information­al programs were completed within 2 weeks of the ITR's de­velopment.

Each department responded differently to the in-service pro­grams; resistance was encountered because some staff felt over­whelmed by the process. Statements such as "This is too muchpaperwork," "We've tried similar things before and they didn'twork," and "We don't have time for this" were heard frequent­ly. Staff were informed, however, that nothing less than 100%compliance would be acceptable. They were also advised that

"Have card, will travel" became a catch phrasefor this interdisciplinary patient education

documentation program.

the nurse managers and the case managers w;ouldbe monitor­ing the ITRs for completeness. After the in-service programswere completed, the IEC reviewed the changes and suggestionsmade by staff and, after making a few modifications, finalizedthe ITR. The procedure for documenting the patient educationprocess was implemented immediately thereafter.

Dealing with implementation challengesAfter implementation began, it took constant reminders by

the nurse managers and frequent tracking by the case managersto ensure that documentation was complete. The interdiscipli­nary approach to documentation made it necessary for the cardsto accompany patients as they attended therapy sessions. As aresult, "Have card, will travel" became a catch phrase for this pro­gram. Because patients' charts remained on the nursing unit,the ITRs were placed in a two-pocket folder that traveled withpatients in their wheelchair bags. However, early after the im­plementation of the ITR, some problems surfaced.

Several concerns arose with the "Have card, will travel"process. Often, nurses or therapists would pull the folders towrite on the cards and then forget to return them to the wheelchairbag. As a result, the cards were unavailable for the next profes­sional to review and complete. Occasionally, nursing staff haddifficulty finding enough time to record their notes on the cardsbefore the patients left for therapy. Therapy staff had the sameproblems trying to document their information on the cards be­fore patients left the department. The result was that, when staffhad time for documentation, the cards were with the patient in an­other area of the hospital. However, as staff became more fa­miliar with and efficient at completing the cards, they were ableto incorporate time for documentation when the ITRs were avail­able. To adjust for the times when more extensive documentationwas required, staff members were instructed to document briefcomments along with an asterisk that indicated that more details

All the authors are affiliated with Hillside Rehabilitation Hospitalin Warren, OH: Susan McCoy and Kelly Cope are case managers,Susan Joy is the manager ofnursing services, Richard Baker is anurse manager, and Christine Brugler is a consultant.

238 Rehabilitation Nursing> Volume 22, Number 5· Sept/Oct 1997

could be found in the patient's computerized entry.Another problem sometimes occurred at the time the patient

was discharged from the hospital. Because the cards were trans­ported in a wheelchair bag with each patient, the folder and bagwere often inadvertently packed with the patients' belongings.On more than one occasion, staff had to make phone calls orsend self-addressed envelopes to retrieve cards that had trav­eled home with the patient. This problem was solved by pur­chasing and using three-ring binders to hold the ITRs, whichmade the ITRs less likely to blend in with the rest of the pa­tient's papers. These binders were also labeled as being the prop­erty of the hospital and contained the printed instruction, "Pleasereturn to the nurses' station," to help ensure their return. Allnursing staff received additional orientation to ensure that theyconsistently retrieved the ITRs.

Celebrating the triumphs of the ITR processDespite all of the initial problems, the ITR process has result~

ed in many benefits. Information on the cards, which can now beretrieved by members of any discipline, allows for better com­munication between departments. The nursing staff can refer tothe cards when they need information about the patients' currenttransfer and ambulation status. Information is also available re­garding what instructions the family has been given by the thera­py departments as well as care instructions given by nursing staff.

Information on the cards can now beretrieved by members ofany discipline,

allowingfor better communication.

JCAHO surveyors arrived right on schedule 6 months later,and the ITR program was a big success. The surveyors award­ed Hillside Rehabilitation Hospital a composite score of 93%and no Type I recommendations. In keeping with the spirit ofthe continuous quality improvementphilosophy so strongly em­braced by the hospital, the interdisciplinary education councildoes not consider this project to be complete. The IEC is look­ing forward to the challenges of computerizing the card andworking as a collaborative team to conquer any future obstacles.

ReferenceMcCourt, A. (Ed.). (1993). The specialty practice ofrehabilitation nursing:

A core curriculum (3rd ed.). Skokie, IL: Rehabilitation Nursing Foundation.

This continuing education offering (codenumber RNC-118) will provide I contacthour to those who read this article and com­plete the application form on page 280 ap­propriately.This independent study offering is appropri­ate for all rehabilitation nurses. By reading

this article, the learner will achieve the following objectives:1. Describe the importance of interdisciplinary documentation

of patient education.2. Identify two solutions to problems faced by interdisciplinary

teams.